GW1-2022-06420_Well Construction - GW1_20220706

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher
Well Contractor Name FROM TO DESCRIPTION
2464-A 13 0rt• T `aft• Q
02 ��ft b
NC Well Contractor Certification Number _. - ... ... _.._
Frank A. Corriher& Sons Well Drilling, Inc. mom D I Tn1CkNESS J MATERIAL
Company Name ft. ft. in.� � 'J _
2.Well Construction Permit#: `!J PROM To DGME R I TR7CkNFSS MATERIAL
List all applicable well construction permits ii.e.U1C,County,State,variance,etc.) +1 fL MNM
fL 6 1/8 '" SDR-21 PVC
3.Well Use(check well use): ft.
Water Supply Well: PROM TO DIAMETER SLOTSIZE TttiCICaM MATERIAL
❑Agricultural OM cipal/Public ft ft. !in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑lrti ation OWells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD Q AMOUNT
Non-Water Supply Well: 0 ft. 22 ft. Bentonite Hole Plug
OMonitoring ❑Recovery ft. ft
Injection Well:
OA uifer Recharge ft. ft.
q arge ❑Groundwater Remediation _
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERtAt. EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
OExperimental Technology OSubsidence Control ft fL
❑Geothemral(Closest Loop) ❑Tracer
OGemthermal(Heating/Cooling Coolin Return3. ❑Other FROM TO D ON color hwdn sovrock
(H � g ) (explain under#21 Remarks) Q � ft. �.�.
4.Date Well(s)Completed: ell ID# to eq C-
r
5a.Well Location: �/ Y fL 3 O
All r { //1///� ft.
Facility/Owner Name a Facility ID#Vwlicabl ft fL
P]1�2rcal A4dress,City,and`LipJUL ft fL 2029
County a Parcel Identification No.(PIN) !
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 4 U
(if well field,one IatAong is sufficient) 22.Certitif n
35p " N 804.0—3 = 7 ii
6.b(are)the well(s): Permanent or OTemporary Signature of Ccr6fiPdWC1l Contractor Date
By signing this form,1 hereby cert6 that the well(s)was(were)constructed in accordance wtih
7.Is this a repair to an existing well: O Yes or ANo /SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner
repair under 421 remarks section or on the back of this form.
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
p 13C — 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:
Tor multiple wells list all depths if different(example-3(a)200'and z 1001 ( ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 24a For All Wells: Original form to Division of Water Resources (DWR),
lfwater level is above casing,use +^ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 610 (in,) 24b.For infection Wells:Copy'to DWR,Underground Injection Control(TUC)
Air Drill Program,1636 MSC,Raleigh,NC 27699-1636
(L Well construction method' 24c.For Water SuoDly and Ocen-Loop Geothermal Return Wells Copy to the
(i e.auger,rotary,cable direct push etc.) courtly environmesital health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells aroducine over 100 000 GPD•Co
PY to DWR,CCPCUA
Permit
13a.Yield(gpm) Method of test:Air Program,1611 MSC,Raleigh,NC 27699-161 I
13b.Disinfection type. Stenlene Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6.6-2018
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